COGNITIVE BEHAVIORAL PLAY THERAPY
ORIGINS OF CBPT
Knell (1998) further developed the approaches of Beck (1976), Ellis (1971), and Bandura (1977) and other theorists, using play to work with children. Knell used structured approach, being directive and goal-oriented, to teach children to think of a new way to play, solve their problems, and build relationships. The application of CBPT includes the assessment and introduction of a customized intervention tailored to “increase behavioral competence” (p. 30). The therapist creates scenes from the child’s life and uses models, role-playing games, desensitization and other techniques to help the child change their behavior (Knell, 1998).
CBPT is a developmentally appropriate therapeutic intervention designed specifically for young children (2 ½ – 8 years). Through this intervention, the child takes an active role in the process of change and mastery of the problems.
CBPT is based on cognitive and behavioral theories of emotional development and psychopathology.
In particular, it derives from Cognitive Therapy (CT), conceptualized by Aaron Beck (1964, 1976).
The Cognitive Therapy (CT) and child development
CT is a structured and directed approach to help individuals change their dysfunctional thoughts and behaviors. It is based on the cognitive model of emotional disorders, whereby maladaptive or disturbed behavior is considered an expression of irrational thinking. CT focuses on the cognitions and modification, in particular of irrational, maladaptive or illogical thinking.
This model, developed for adults, is applicable to children too, but young children do not have sufficient cognitive skills and flexibility to benefit from CT. CT requires the ability to follow a logical and rational sequence and the ability to distinguish between rational and irrational / logical and illogical thinking, skills that have not yet developed.
In the preoperational stage of the child’s development, thinking is self-centered, concrete and irrational by nature, and action may precede thinking due to cognitive immaturity or impulsiveness.
These characteristics make the use of CT problematic, thus, it is necessary to adapt it to practice with children and adolescents, in order to guarantee a more adequate approach to their development.
Knell and her colleagues have demonstrated that cognitive behavioral therapy can be communicated to children through play (Knell, 1993a, 1994, 1997, 1998, 1999; Knell & Moore, 1990; Knell & Ruma, 1996, 2003; Knell & Dasari, 2006).
Adapting CT for use with children
According to Knell (1993a, 1993b, 1994, 1997, 1998), CT could be applied to children if presented in a way accessible to them. Puppets, stuffed animals, books and other toys can be used to model children’s cognitive strategies, verbalizing the ability to solve problems or find possible solutions to a problem similar to the child’s.
CBPT, as conceptualized by Knell (1993a, 1993b, 1994, 1997, 1998, 1999, 2000; Knell & Moore, 1990; Knell & Ruma, 1996, 2003; Knell & Beck, 2000, Knell & Dasari, 2006) was developed for use with children between 2½ and 8 years and is based on cognitive, behavioral and traditionally therapies. CBPT is sensitive to developmental issues and emphasizes the empirical validation of effectiveness of interventions.
Level of development of the child
In order for an intervention to be appropriate, its complexity must consider the child’s developmental stage. The CBPT therapist should:
- focus on the child’s strength and abilities rather than focusing on weaknesses;
- focus on experiential interventions that incorporate play rather than complex and verbal skills;
- encourage and facilitate language to described experiences and emotions.
The child’s vocabulary is still often quite limited. Young children often benefit from the opportunity to learn to associate behaviors with their feelings and express feelings in more adaptive language-based ways.
For example, rather than expressing frustration and anger through aggressive behavior, the child can be taught how to understand when he is angry and to express that feeling through words rather than behavior. In doing so, the child can acquire a sense of control and mastery, as well as more positive feedback from the adults around them.
For children, play is a natural and developmentally appropriate means of communication. So, children can use toys as their words and play as communication/language.
TREATMENT DESCRIPTION: CBPT STAGES
CBPT is divided into several phases, described as introductory/orientation, assessment, middle, and termination stages.
For a more complete description of these stages in CBPT, see Knell (1999).
BALANCE BETWEEN STRUCTURED PLAY AND UNSTRUCTURED PLAY
In CBPT, the balance between structured and goal-oriented activities and unstructured activities in which child’s spontaneity emerges is fundamental.. Unstructured and spontaneous information is critical because it allows the therapist to obtain many clinical information, that the child feeling in a safe context has the opportunity to bring out.
The child expresses his needs through play and the therapist in recognizing them gives him all the expressive space without intervening and interpreting, but accepting and recognizing the precious moment of communication. Thanks to this space, structured therapy can plan an intervention that involves teaching more adaptive behaviors and strategies.
CBPT: SIMILARITIES/DIFFERENCES WITH THE TRADITIONAL PLAY THERAPIES
Historically, play therapy has been based on either psychodynamic or client-centered theories, such as Child-Centered Play Therapy (Axline, 1947). CBPT is different from these more traditional forms of play therapies, but has similarities to them in its reliance on a positive therapeutic relationship, use of a play as a means of communication between therapist and child, and therapy as a safe place.
Several important areas of differences involve: the focus on CBPT on directions and goals, choice of play materials and activities, play as educational, and the importance of making connections between the child’s behavior and thoughts.
The CBPT therapist can introduce themes, selects play materials and activities with the child, and provides a psychoeducational component to the treatment. This helps impart positive coping skills and alternatives to the current maladaptive ways. Finally, CBPT brings child’s conflicts and problems into verbal expression, helping the child make connections between words and behavior (See Knell, 1993a, for more details).
THE EFFECTIVENESS OF CBPT
This can be expressed by six specific characteristics:
1. Involves the child in therapy through play. The child is an active participant and the problems of resistance and lack of compliance can be more easily addressed. In addition, the therapist can address the child’s problems directly, rather than through a parent or significant adult.
2. Focuses on the child’s thoughts, feelings, fantasies and environment.
3. Proposes a strategy, or strategies, for the development of adaptive thoughts and behaviors that can help the child deal with situations and feelings. In fact, the positive outcome of the therapy provides that
the child will become able to replace maladaptive modalities, and to cope with events with more adaptive approaches.
4. It is a structured, directive and goal-oriented therapy rather than open- ended. The therapist works with the child and the family to set goals and helps them work towards achieving the set goals.
5. It emphasizes the use of empirically demonstrated techniques: one of the most important and utilized techniques is that of modeling (implemented for example by the therapist through the use of puppets and dolls). This, in fact, responds to the need for concrete and non-verbal demonstrations, particularly when addressing children of preschool age.
6. CBPT allows empirical control of treatment.
Finally, the CBPT interventions are adapted to the developmental age of the child, that which are part of cognitive-behavioral therapy (CBT) interventions.
So, in Cognitive Behavioral Play Therapy (CBPT), play is used as a means of communicating and teaching evidence-based techniques to children aged 3 to 8, indirectly and engagingly.